Provider Demographics
NPI:1093997504
Name:MACIAS, ELIASAR BENJAMIN (PA)
Entity Type:Individual
Prefix:
First Name:ELIASAR
Middle Name:BENJAMIN
Last Name:MACIAS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 SESPE AVE
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:CA
Mailing Address - Zip Code:93015-1957
Mailing Address - Country:US
Mailing Address - Phone:805-524-2559
Mailing Address - Fax:805-524-2596
Practice Address - Street 1:427 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:CA
Practice Address - Zip Code:93015
Practice Address - Country:US
Practice Address - Phone:805-524-2559
Practice Address - Fax:805-524-2596
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA19432AMedicare PIN